Healthcare Provider Details

I. General information

NPI: 1306235486
Provider Name (Legal Business Name): MRS. JESSICA WRAY KUKESH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2015
Last Update Date: 02/04/2020
Certification Date: 02/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 N SUNRISE AVE
ROSEVILLE CA
95661-2924
US

IV. Provider business mailing address

2048 GERBER AVE
SACRAMENTO CA
95817-1321
US

V. Phone/Fax

Practice location:
  • Phone: 916-771-8255
  • Fax:
Mailing address:
  • Phone: 209-324-0462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP21667
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: